Wilmington Health Orthopaedics and Sports Medicine, Wilmington, NC, USA.
Medical College of Wisconsin, Milwaukee, WI, USA.
J Shoulder Elbow Surg. 2024 Jun;33(6):e336-e342. doi: 10.1016/j.jse.2023.10.004. Epub 2023 Nov 20.
Prior authorization review (PAR), in the United States, is a process that was initially intended to focus on hospital admissions and costly high-acuity care. Over time, payors have broadened the scope of PAR to include imaging studies, prescriptions, and routine treatment. The potential detrimental effect of PAR on health care has recently been brought into the limelight, but its impact on orthopedic subspecialty care remains unclear. This study investigated the denial rate, the duration of care delay, and the administrative burden of PAR on orthopedic subspecialty care.
A prospective, multicenter study was performed analyzing the PAR process. Orthopedic shoulder and/or sports subspecialty practices from 6 states monitored payor-mandated PAR during the course of providing routine patient care. The insurance carrier (traditional Medicare, managed Medicare, Medicaid, commercial, worker's compensation, or government payor [ie, Tricare, Veterans Affairs]), location of service, rate of approval or denial, time to approval or denial, and administrative time required to complete process were all recorded and evaluated.
Of 1065 total PAR requests, we found a 1.5% (16/1065) overall denial rate for advanced imaging or surgery when recommended by an orthopedic subspecialist. Commercial and Medicaid insurance resulted in a small but statistically significantly higher rate of denial compared to traditional Medicare, managed Medicare, worker's compensation, or governmental insurance (P < .001). The average administrative time spent on a single PAR was 19.5 minutes, and patients waited an average of 2.2 days to receive initial approval. Managed Medicare, commercial insurance, worker's compensation, and Medicaid required approximately 3-4 times more administrative time to process a PAR than to traditional Medicare or other governmental insurance (P < .001). After controlling for the payor, we identified a significant difference in approval or denial based on geographic location (P < .001). An appeal resulted in a relatively low rate of subsequent denial (20%). However, approximately a third of all appeals remained in limbo for 30 days or more after the initial request.
This is the largest prospective analysis to date of the impact of PAR on orthopedic subspecialty care in the United States. Nearly all PAR requests are eventually approved when recommended by orthopedic subspecialists, despite requiring significant resource use and delaying care. Current PAR practices constitute an unnecessary process that increases administrative burden and negatively impacts access to orthopedic subspecialty care. As health care shifts to value-based care, PAR should be called into question, as it does not seem to add value but potentially negatively impacts cost and timeliness of care.
在美国，预先授权审查（PAR）最初是为了关注住院和高成本的高 acuity 护理而设立的。随着时间的推移，支付方已经将 PAR 的范围扩大到包括影像学研究、处方和常规治疗。PAR 对医疗保健的潜在不利影响最近受到了关注，但它对骨科亚专科护理的影响尚不清楚。本研究调查了 PAR 对骨科亚专科护理的拒付率、护理延误时间和行政负担。
进行了一项前瞻性、多中心研究，分析了 PAR 流程。来自 6 个州的骨科肩部和/或运动亚专科实践在提供常规患者护理的过程中监测支付方规定的 PAR。保险商（传统医疗保险、管理式医疗保险、医疗补助、商业、工人赔偿或政府支付方[即 Tricare、退伍军人事务部]）、服务地点、批准或拒付率、批准或拒付时间以及完成流程所需的行政时间均被记录并进行了评估。
在 1065 项 PAR 请求中，我们发现当骨科专家建议进行高级影像学检查或手术时，整体拒付率为 1.5%（16/1065）。与传统医疗保险、管理式医疗保险、工人赔偿或政府保险相比，商业保险和医疗补助的拒付率略高，但具有统计学意义（P<0.001）。处理单个 PAR 的平均行政时间为 19.5 分钟，患者平均需要等待 2.2 天才能获得初始批准。管理式医疗保险、商业保险、工人赔偿和医疗补助处理 PAR 所需的行政时间比传统医疗保险或其他政府保险多约 3-4 倍（P<0.001）。在控制支付方的情况下，我们发现基于地理位置的批准或拒付存在显著差异（P<0.001）。上诉导致随后的拒付率相对较低（20%）。然而，大约三分之一的上诉在初始请求后 30 天或更长时间仍处于悬而未决状态。
这是迄今为止对美国 PAR 对骨科亚专科护理影响的最大前瞻性分析。尽管需要大量资源并延迟护理，但几乎所有 PAR 请求最终都会在骨科专家建议下获得批准。目前的 PAR 做法构成了一种不必要的流程，增加了行政负担，并对获得骨科亚专科护理产生负面影响。随着医疗保健向基于价值的护理模式转变，PAR 应该受到质疑，因为它似乎没有增加价值，反而可能对成本和护理及时性产生负面影响。
